Children's mental health is in crisis
Updated 2 years ago on October 17, 2022
"People call me and say, 'Me and my child have been in the emergency room for days waiting for a bed. My child is suicidal. We can't go home... And I am terrified. What can I do? What can you do to help?" - says Donna Martin, M.D., Ph.D., chair of the Department of Pediatrics, Ravitz Foundation Distinguished Professor of Pediatrics and Infectious Diseases and professor of human genetics.
"And that's just wrong."
The situation is difficult. But it is not new.
"We've been shouting from the rooftops, saying we have a crisis," says Emily Fredericks, PhD, professor of pediatrics and director of the department of child psychology at Michigan Medical Center. "We don't have enough psychologists on staff to meet the needs of children. We knew we were in a difficult situation.
"The pandemic made it worse. Indefinitely."
"I've said it so often that it sounds trite," said Gregory Dalak, M.D., Daniel E. Offutt Professor of Psychiatry, III and chairman of the department. "All of these needs existed. The pandemic just squeezed the vise of the system."
This compression caused an unprecedented event last fall when the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association declared a national child and adolescent mental health emergency.
"We have thousands of patients waiting to access outpatient child psychiatry services in our health care system and in the community," says Nasuh Malas, M.D., associate professor of psychiatry and pediatrics and head of child psychiatry services at C.S. Mott Children's Hospital .
Malas and colleagues published a study in January in the journal Clinical Pediatrics that shows an 18% increase in primary psychiatric consultations at C.S. Mott Children's Hospital from July 2020 to January 2021 compared to the 2019-2020 period .
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This is a fourfold increase in demand for mental health counseling compared to the rate of growth in previous years.
And it's not just because the volume of demand has increased, but also because of the severity of the problem of individual patients.
A Michigan Medicine study published in March in the journal Clinical Child Psychology and Psychiatry shows that pediatric patients who received the services of a psychiatrist and/or psychologist during the pandemic were more likely to need restrictions and antipsychotics than those who were treated immediately before the pandemic. "We used to see intermediate severity," Fredericks says. "Now every patient causes me concern."
As with natural disasters, this crisis has its heroes, both the visionaries who foresaw it and spent many years preparing, and those who have been called into action at this acute pain point. But more than individual heroes, broad systemic change is needed, according to the many mental health experts interviewed for this article.
We have a tsunami of needs all over the country, and we only have sandbags to meet them.
Below are seven actions that health care and the country can take to help alleviate this crisis. Most of them are already being implemented at Michigan Medicine - Mott, the Nyman Family Unit for Child and Adolescent Mental Health and Wellness, the Eisenberg Family Depression Center, and many child mental health clinics.
1. train more service providers
"The number of child psychiatrists has always been tiny, paltry - never close to a reasonable number for the population," says Laura Hirschbein, MD, PhD, professor of psychiatry, who is also a historian who writes books on the history of child mental health. In Michigan, Washtenaw County alone has a sufficient number of child and perinatal psychiatrists.
Historically, "child psychiatrists have been pretty low-paid among medical specialties," says Sheila Marcus, M.D., professor of psychiatry. "And at the end of five years of post-medical school, these aspiring physicians were struggling with student loans."
The Michigan Department of Health and Human Services now has a loan repayment program for mental health workers who work for two years in nonprofit medical clinics in health professions shortage areas or child and adolescent psychiatry inpatients.
"We're training more child psychologists," Fredericks said. "But the interest is greater than the number of places available. There has been national advocacy for more federal funding for training child and adolescent psychologists."
However, we are still far from what we need.
"As a health care system, we need more investment in psychologists," Martin said. "We could have four times as many psychologists as we have now and still fall short."
Hirschbein said that "pediatricians are taking on the role of primary mental health providers."
In fact, most psychiatric prescriptions for children are made by primary care physicians.
"Families like to be treated in primary care because they are comfortable with the doctor and because there are no stigma issues," Marcus said.
"The question is, 'How can we spread the experience so people know what to do [when families with mental health issues come to them]?" said Hirschbein.
One answer is the Michigan Shared Child Care Program, also known as MC3.
Marcus founded the program ten years ago when she saw how difficult it was for primary care physicians to meet the growing demand for mental health care. MC3 partners with the Michigan Department of Health and Human Services to support primary care physicians responding to mental health crises.
When a primary care provider initiates a consultation with MC3, the behavioral health counselor will triage the request by answering questions within their area of expertise and referring appropriate cases to a Michigan Medicine psychiatrist for a same-day telephone consultation. In many cases, the behavioral health counselor also identifies local resources for the patient.
MC3 has been able to leverage the expertise of several Michigan Medical Center psychiatrists to meet the needs of children and women across the state. As of March 2022, MC3 had 3,100 providers registered, responded to 38,000 inquiries and helped 16,000 patients.
The MC3 program is also one of several in the country with a thriving perinatal counseling program that provides counseling to primary care physicians who monitor women during pregnancy and after delivery.
"When mothers with depression and trauma are identified early on, it allows counselors to refer them to infant mental health professionals who help form healthy, secure attachment relationships with their babies," Marcus says. "This early attachment helps ensure that infants have a healthy developmental trajectory from the beginning."
MC3 also provides ongoing training for primary care physicians in mental health through educational modules on topics such as eating disorders, ADHD and other mental health issues. Training these physicians to become better mental health professionals is one way MC3 has helped increase the number of physicians able to meet the needs of the crisis.
2. Implement innovations to increase access
Mental health problems are common. Approximately one in five children has a diagnosable mental illness, but only half of them receive proper care. Although holistic medicine and whole person care are widely recognized and generally praised as important, mental health care is too often isolated in specialized practices that remain out of reach for many families.
"We need to make mental health care as accessible to everyone as physical care," says Joanna Quigley, M.D., associate professor of psychiatry and pediatrics and associate medical director of outpatient mental health services for children and adolescents. "It should be as simple as seeing a primary care physician to check on a child's health."
This is an area where the broader health care community can use large health care systems like Michigan Medicine as an example to follow. At Mott, psychology and psychiatry services are fully integrated into children's health care. "Integrating psychologists where children get care provides better care and better access," says Christine Kullgren, Ph.D., assistant professor of pediatrics.
"We're thinking about how to more thoughtfully integrate care and embed mental health professionals into health care settings," said Malas, who runs the mental health counseling service at Mott. "We're working with health care providers to ensure early screening and preventive services."
Another relatively rare innovation that has improved access to mental health care is telemedicine or virtual care.
Before the pandemic, Kullgren conducted only one virtual visit. But now she is a big proponent of telemedicine, especially in the area of children's mental health.
"For me and my patients, virtual care has many positive aspects," Kullgren said. "For kids, accessibility is huge. They can log in from home, from school, from a McDonald's parking lot, wherever they are, and I can give them care. Whereas it used to take half a day or a day to get to an appointment, now it only takes an appointment time."
In addition to integrating mental health care with medical care and further expanding access to mental health care through telemedicine, we also need to come up with innovative ways to reduce the current burden on psychiatric acute care services.
Currently, according to Malas, Nyman's family unit's psychiatric beds for children are 95 percent full, with six to eight children waiting their turn for a psychiatric bed.
Some may wait a few days, but the answer is not necessarily more beds.
"We need to provide patient care locally and early, and in a way that is feasible, sustainable and natural, not having people come to the emergency room in the middle of the night in a crisis situation," Malas said.
He also recommends expanding mental health services "so it's not just an outpatient/inpatient model." He says we need urgent care centers equipped to deal with mental health issues, respite centers for adolescents who need a cooling-off period, and partial hospitalization programs.
Malas and Quigley are part of a group that is developing a partial hospitalization program for children and adolescents. Such a program could provide mid-level psychiatric care, similar to the partial hospitalization program that already exists for adults.
"We have to change our framework so we don't think of mental health care as something that happens only in the mental health clinic," Quigley said. "We have to integrate that care into all aspects of the care process."
3. Improve insurance coverage
For many families, access to mental health care is almost synonymous with having insurance coverage. But from an insurance perspective, mental health and physical health are not viewed in the same way.
"Insurance companies have gone to a very aggressive management of mental health care to get providers to prove that someone really needs it in a way that they don't for other illnesses," Hirschbein said.
Jack Kaufman, Ph.D., professor at the Association for Physical Medicine and Rehabilitation, suggests changing federal regulation in terms of the perception of insurance .
"We don't need insurance companies telling us how many units of anything they're going to give us to solve a problem before we even diagnose it," said Kaufman, who also does neuropsychological testing for children, which, like all mental health services, is seeing an increase in demand.
Kaufman also says it's important to make sure that the same services are reimbursed at the same rate by insurance - regardless of who provides them. For example, she says, a psychotherapy session may pay a higher rate for a doctor than for a psychologist, even though such a session does not require medical training.
"There are services that I, as a psychologist, can't do, they cost more, and that makes sense. But the service should pay the same if it's the same service."
Making this change in insurance coverage may encourage a broader range of mental health professionals to be involved in meeting the demand for psychological services.
It also needs to make it easier for mental health providers in the community to get insurance coverage. One of the reasons large health systems like Michigan Medicine have such long waiting lists is that they are often the only recourse for families who cannot afford to pay for mental health care out of their own resources.
4. Learn more about children's brains
"The period of preschool, adolescence and early adulthood is really the time when mental health problems arise," says Mary Heitzeg, PhD, professor of psychiatry. "It's also a time when the brain goes through critical developmental processes."
Heitzeg and Chandra Sripada, MD, PhD, assistant professor of psychiatry, are principal investigators in the Adolescent Brain Cognitive Development Study, also known as ABCD. This groundbreaking nationwide study involves 21 centers collecting data on 11,800 adolescents (720 of whom attend Michigan Medical Center). According to Heitzeg, before this study began six years ago, the really impressive sample size for such a study would have been 100 people.
Each year, each of the registered youths and one of their parents undergo an eight-hour screening. It includes neurocognitive tasks as well as a large set of questionnaires that provide data on everything from sleep quality and substance use to screen time and extracurricular activities. Initially, and every two years thereafter, the assessment includes fMRI to record changes in the brain. Researchers also collect data in the middle of each year.
But how can having all this data improve children's mental health?
This is where another technological advancement comes to the rescue: data sharing.
Study data are available to researchers around the world, and about 400 studies based on ABCD have been published to date, Sripada says. The richness of the data set allows for an astonishing array of interpretations that can have profound implications for children.
"One of the things ABCD has helped us definitively establish is that socioeconomic factors -- household resources, income relative to need, disadvantaged neighborhood, and parental education -- have a big impact on children's brains, on brain structure, on patterns of communication, and on how the brain responds to tasks," Sripada said. "It can have some policy implications."
Heitzeg notes that the longitudinal nature of the study will also allow researchers to see the outcomes associated with these brain changes. "Do they have a greater risk of mental health problems, do they do worse in school, etc.?"
Heitzeg says another merit of the study is that "we have all the rest of the information. For example, organized sports. Theoretically, we can have a group of kids with the same socioeconomic status and the same brain changes, but they play sports and the other group doesn't. We can see how a potential protective factor like [sports] can affect outcomes."
Robert Zucker, Ph.D., current professor emeritus of psychiatry and psychology, director emeritus of the University of Michigan Addiction Center and one of the principal investigators of the ABCD study, said that "the last piece of the puzzle is the impact of macro-environmental events like COVID-19, or the profound and long-term effects of a major military disaster like in Ukraine ."
Zucker has been interested throughout his career in the causes and treatment of mental health problems and has conducted research on the origins of behavioral problems and substance abuse in children to explore these issues.
The study lasted 31 years, beginning in 1985 with children between the ages of three and five, the earliest developmental age ever studied in this way. It also included data on the parents of these children, and it was the longest study of the matrix of family interaction for its potential contribution to or protection from these problems.
Zucker emphasizes the importance of understanding that the impact of major historical events on generational health is likely an interaction with the mental health adaptations and social resources of the youth who experienced these events.
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ABCD researchers realized this, too. When the pandemic began, ABCD researchers quickly switched to including questions about the effects of COVID-19 on families in their assessments. This study is already tracking these effects over time, and early results show this interaction.
"Most mental health problems and concerns are long-term and chronic," Zucker said. "They remit. But cure - complete cure - is relatively rare. The solution to this problem from a public health perspective is prevention." The detailed knowledge gained from ABCD is able to determine what goals should be set for this long-term prevention."
5. Prevent mental illness
What is the ideal age to begin helping children promote mental health and prevent mental illness? At Zero to Thrive, or Z2T, the answer is before birth.
Located in the Department of Psychiatry, Z2T provides mental health services to individuals and families from conception through early childhood.
"The scientific evidence is clear: Brain development in the earliest years lays a critical foundation for later well-being, and early relationship health interventions have demonstrated a high return on investment," says Maria Muzik, MD, MSc, co-director of Z2T and assistant professor of psychiatry and obstetrics and gynecology. "Effective programs must address critical mental health needs not only through access to mental health care, but also by reducing the social isolation that many families experience, supporting parents in meeting their own emotional needs and those of their children, and connecting families to resources in the community to meet the full range of family needs."
Z2T teaches the importance of healthy relationships at an early age and what a caregiver-infant relationship looks like. When caregivers are positive and responsive, the child's brain receives the stimulation it needs to form the neural pathways necessary to build resilience and thrive.
Medical school interns work in both a perinatal clinic serving pregnant and postpartum women and an infant and toddler clinic serving families from birth to age six, using advanced surveillance and feedback technology to support and develop family strengths.
"While our clinic-based services are critical, if we wait for families to turn to us for psychiatry, we're only reaching the tip of the iceberg," says Catherine Rosenblum, PhD, co-director of Z2T and professor of psychiatry, pediatrics, obstetrics and gynecology. "That's why we focus on partnering with community organizations, offering training to multidisciplinary professionals in perinatal and early childhood mental health, and thus reaching families where they already are, from pediatric primary care to early care and education to other community programs."
A key part of Z2T is the Strong Roots series of programs that help children by building the resilience of families, especially those who have been adversely affected by trauma, economic oppression or inequality.
Studies of these programs have demonstrated positive effects on both parents and children, including improved early relationships, changes in parental brain patterns that are associated with decreased parental stress, increased social connections with other parents, and increased use of community services .
There are programs for moms ("Mommy Power"), dads ("Fathers Brotherhood") and military families, as well as a program for early childhood educators who work with infants and children in preschools and nurseries. Z2T has trained professionals who implement these programs in community organizations across the country. Z2T also conducts research, educational initiatives and a clinical venture to help pregnant and postpartum women with mental health issues.
"Schools, primary care providers and local community resources must find ways to integrate mental health and wellness into all of their cases," Malas said. "We need to see mental health as a shared responsibility of all professionals working with children and families."
Another program started at Michigan Medical that uses this integrated mental health model is TRAILS, or Transforming Research into Action to Improve the Lives of Students. TRAILS equips school staff with the training, resources, and clinical tools needed to implement three levels of programs: Social and Emotional Learning to build student resilience and self-management skills, and self-care strategies for staff to cope with stress and burnout; early intervention for students with mental health problems; suicide risk management; and crisis care coordination for students.
Research shows that students receiving cognitive behavioral therapy and mindfulness training offered by TRAILS had a 16.9% reduction in symptoms of depression and/or anxiety, and increased use of self-regulation and coping skills.
The Eisenberg Family Depression Center also offers a peer-to-peer program that began in 2009. The program teaches middle and high school students about depression and depressive illnesses and helps them find creative ways to communicate that knowledge to their peers. In 2019, the program received the American Psychiatric Association's Gold Award for Academic Programs.
6. Help your helpers
Meeting the needs of mental health providers is a key component of protecting children's mental health.
A small change that could help these providers is to deepen their understanding of multiple mental health specialties.
"Would you send a man with a sick stomach to a dermatologist?" asked Kaufman.
She often receives inappropriate referrals because referring physicians are unaware of the full range of specialties in psychology and where to go with a particular problem. For example, the neuropsychological testing that Kaufman does is primarily directed at cognitive problems and diagnosis rather than behavioral or mood treatment, but one might assume that she deals with patients with these latter problems because she is a psychologist.
It's not just that it's frustrating to get an inappropriate referral, but it's an inefficiency in the mental health care system that, if corrected, could free up specialized providers to offer the right care to the right patient at the right time.
The greater challenge is to better support service providers.
"The mental health of mental health workers is at a very low point right now," Kaufman said. "We're people who listen to everyone who is in crisis."
At the beginning of the pandemic, Kaufman and other psychotherapists from Michigan Medicine teamed up to support frontline health workers. The 200 volunteers provided face-to-face and virtual counseling to their Michigan Medicine colleagues who were experiencing the worst effects of the pandemic. They also helped educate them about how trauma affects mental health and what they can expect over time.
Now there is a huge burden on these volunteers because the demand for mental health care far exceeds the supply of providers.
"Appreciation is best shown by listening, hearing and participating in what's going on," Kaufman said.
She believes that a meaningful first step toward helping the mentally ill would be to honestly acknowledge how they are suffering.
7. Change the conversation
In the late 1960s Congress commissioned a study that resulted in a report entitled " The Crisis of Child Mental Health. According to Hirschbein, "It talked about such things as systemic racism, [showing] that there was no way poor black children could survive and thrive under such conditions.
What is striking about this report is that there is nothing in it about psychiatric diagnoses or medications.
"Child psychiatrists at the time were mostly psychoanalysts, but they were also activists," Hirschbein says. "They wanted the government to do something to help children. They wanted big social change."
The "Child Mental Health Crisis " report was initiated during President Johnson's administration, "but it ended up on President Nixon's desk, where it quickly died. No great social change was in sight.
In the 1990s and 2000s, psychiatric drugs for children became more affordable and commercialized.
"The idea of diagnosing, treating and focusing on mental illness has been a real shift in child psychiatry," says Hirschbein. "However, the number of children who meet the criteria for mental illness is not decreasing. Something is going on, and we are moving in the wrong direction."
Hirschbein thinks it would be helpful to bring the conversation back to the question that the 500 experts who worked on the report " Child Mental Health Crisis " were asking: "What does it mean to raise a child to be healthy?"
One answer is to help children learn basic social skills and rules of courtesy, which Martin considers victims of the pandemic.
"The skills we need to function as a society are now at risk," she said. "We have lost the social fabric of our communication, and Zoom will not replace personal communication."
Martin believes that the isolation caused by the pandemic is especially dangerous for children who are just learning to be social. She is also concerned that uncivil discourse on the Internet is on the rise.
"How do we course-correct in a society where sarcasm, accusations or, frankly, insults become the norm?" - Martin asked. asked Martin. "If you're a kid growing up in that kind of environment, I worry about what you're going to look like in 10 years. It's really scary. How do we create these meaningful interactions for families, individuals and communities?"
A positive aspect of the pandemic was the change in public conversations about mental health.
"We've come a long way in addressing mental health stigma," Martin said.
Quigley thinks it's great that more professional organizations and the State of the Union address are talking about the mental health crisis.
"But this problem started long before COVID-19, and I hope it continues to get people's attention and investment because it's not going anywhere," he said. "There's going to be a whole generation of kids affected by COVID-19 who are going to have ongoing needs. I think of my 3.5-year-old daughter ... COVID-19 is the life she remembers." The effects will be felt for a long time to come."
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